Provider Demographics
NPI:1932360161
Name:SMALL, SHANNON F (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:F
Last Name:SMALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 E CARPENTER ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-5324
Mailing Address - Country:US
Mailing Address - Phone:217-757-6570
Mailing Address - Fax:
Practice Address - Street 1:800 E CARPENTER ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5324
Practice Address - Country:US
Practice Address - Phone:217-757-6570
Practice Address - Fax:217-757-6573
Is Sole Proprietor?:No
Enumeration Date:2008-06-20
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012490012086S0102X
IL0361436862086S0102X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care